A7 Final Review
A nurse teaches a client who is prescribed digoxin (Lanoxin) therapy. Which statement should the nurse include in this client's teaching? a. "Avoid taking aspirin or aspirin-containing products." b. "Increase your intake of foods that are high in potassium." c. "Hold this medication if your pulse rate is below 80 beats/min." d. "Do not take this medication within 1 hour of taking an antacid."
ANS: D Gastrointestinal absorption of digoxin is erratic. Many medications, especially antacids, interfere with its absorption. Clients are taught to hold their digoxin for bradycardia; a heart rate of 80 beats/min is too high for this cutoff. Potassium and aspirin have no impact on digoxin absorption, nor do these statements decrease complications of digoxin therapy.
A nurse reviews laboratory results for a client with diabetes mellitus who presents with polyuria, lethargy, and a blood glucose of 560 mg/dL. Which laboratory result should the nurse correlate with the client's polyuria? a. Serum sodium: 163 mEq/L b. Serum creatinine: 1.6 mg/dL c. Presence of urine ketone bodies d. Serum osmolarity: 375 mOsm/kg
ANS: D Hyperglycemia causes hyperosmolarity of extracellular fluid. This leads to polyuria from an osmotic diuresis. The client's serum osmolarity is high. The client's sodium would be expected to be high owing to dehydration. Serum creatinine and urine ketone bodies are not related to the polyuria.
A nurse assesses a client who is prescribed furosemide (Lasix) for hypertension. For which acid-base imbalance should the nurse assess to prevent complications of this therapy? a. Respiratory acidosis b. Respiratory alkalosis c. Metabolic acidosis d. Metabolic alkalosis
ANS: D Many diuretics, especially loop diuretics, increase the excretion of hydrogen ions, leading to excess acid loss through the renal system. This situation is an acid deficit of metabolic origin.
A nurse is caring for a client who is experiencing moderate metabolic alkalosis. Which action should the nurse take? a. Monitor daily hemoglobin and hematocrit values. b. Administer furosemide (Lasix) intravenously. c. Encourage the client to take deep breaths. d. Teach the client fall prevention measures.
ANS: D The priority nursing care for a client who is experiencing moderate metabolic alkalosis is providing client safety. Clients with metabolic alkalosis have muscle weakness and are at risk for falling. The other nursing interventions are not appropriate for metabolic alkalosis.
A nurse cares for a client experiencing diabetic ketoacidosis who presents with Kussmaul respirations. Which action should the nurse take? a. Administration of oxygen via face mask b. Intravenous administration of 10% glucose c. Implementation of seizure precautions d. Administration of intravenous insulin
ANS: D The rapid, deep respiratory efforts of Kussmaul respirations are the body's attempt to reduce the acids produced by using fat rather than glucose for fuel. Only the administration of insulin will reduce this type of respiration by assisting glucose to move into cells and to be used for fuel instead of fat. The client who is in ketoacidosis may not experience any respiratory impairment and therefore does not need additional oxygen. Giving the client glucose would be contraindicated. The client does not require seizure precautions.
A nurse is caring for a client who was prescribed high-dose corticosteroid therapy for 1 month to treat a severe inflammatory condition. The clients symptoms have now resolved and the client asks, When can I stop taking these medications? How should the nurse respond? a. It is possible for the inflammation to recur if you stop the medication. b. Once you start corticosteroids, you have to be weaned off them. c. You must decrease the dose slowly so your hormones will work again. d. The drug suppresses your immune system, which must be built back up.
B (One of the most common causes of adrenal insufficiency, a life-threatening problem, is the sudden cessation of long-term, high-dose corticosteroid therapy. This therapy suppresses the hypothalamic-pituitary-adrenal axis and must be withdrawn gradually to allow for pituitary production of adrenocorticotropic hormone and adrenal production of cortisol. Decreasing hormone therapy slowly ensures self-production of hormone, not hormone effectiveness. Building the clients immune system and rebound inflammation are not concerns related to stopping high-dose corticosteroids.)
After teaching a client who is recovering from an endoscopic trans-nasal hypophysectomy, the nurse assesses the clients understanding. Which statement made by the client indicates a correct understanding of the teaching? a. I will wear dark glasses to prevent sun exposure. b. Ill keep food on upper shelves so I do not have to bend over. c. I must wash the incision with peroxide and redress it daily. d. I shall cough and deep breathe every 2 hours while I am awake.
B: Ill keep food on upper shelves so I do not have to bend over. (After this surgery, the client must take care to avoid activities that can increase intracranial pressure. The client should avoid bending from the waist and should not bear down, cough, or lie flat. With this approach, there is no incision to clean and dress. Protection from sun exposure is not necessary after this procedure.)
A nurse assesses clients at a community health fair. Which client is at greatest risk for the development of hepatitis B? a. A 20-year-old college student who has had several sexual partners b. A 46-year-old woman who takes acetaminophen daily for headaches c. A 63-year-old businessman who travels frequently across the country d. An 82-year-old woman who recently ate raw shellfish for dinner
A: A 20-year-old college student who has had several sexual partners. Hepatitis B can be spread through sexual contact, needle sharing, needle sticks, blood transfusions, hemodialysis, acupuncture, and the maternal-fetal route. A person with multiple sexual partners has more opportunities to contract the infection. Hepatitis B is not transmitted through medications, casual contact with other travelers, or raw shellfish. Although an overdose of acetaminophen can cause liver cirrhosis, this is not associated with hepatitis B. Hepatitis E is found most frequently in international travelers. Hepatitis A is spread through ingestion of contaminated shellfish.
An emergency department nurse assesses a client with ketoacidosis. Which clinical manifestation should the nurse correlate with this condition? a. Increased rate and depth of respiration b. Extremity tremors followed by seizure activity c. Oral temperature of 102° F (38.9° C) d. Severe orthostatic hypotension
ANS: A Ketoacidosis decreases the pH of the blood, stimulating the respiratory control areas of the brain to buffer the effects of increasing acidosis. The rate and depth of respiration are increased (Kussmaul respirations) in an attempt to excrete more acids by exhalation. Tremors, elevated temperature, and orthostatic hypotension are not associated with ketoacidosis.
A nurse assesses a client who is admitted with an acid-base imbalance. The client's arterial blood gas values are pH 7.32, PaO2 85 mm Hg, PaCO2 34 mm Hg, and HCO3- 16 mEq/L. What action should the nurse take next? a. Assess client's rate, rhythm, and depth of respiration. b. Measure the client's pulse and blood pressure. c. Document the findings and continue to monitor. d. Notify the physician as soon as possible.
ANS: A Progressive skeletal muscle weakness is associated with increasing severity of acidosis. Muscle weakness can lead to severe respiratory insufficiency. Acidosis does lead to dysrhythmias (due to hyperkalemia), but these would best be assessed with cardiac monitoring. Findings should be documented, but simply continuing to monitor is not sufficient. Before notifying the physician, the nurse must have more data to report.
A nurse cares for a client with hepatopulmonary syndrome who is experiencing dyspnea with oxygen saturations at 92%. The client states, "I do not want to wear the oxygen because it causes my nose to bleed. Get out of my room and leave me alone!" Which action should the nurse take? a. Instruct the client to sit in as upright a position as possible. b. Add humidity to the oxygen and encourage the client to wear it. c. Document the client's refusal, and call the health care provider. d. Contact the provider to request an extra dose of the client's diuretic.
ANS: A The client with hepatopulmonary syndrome is often dyspneic. Because the oxygen saturation is not significantly low, the nurse should first allow the client to sit upright to see if that helps. If the client remains dyspneic, or if the oxygen saturation drops further, the nurse should investigate adding humidity to the oxygen and seeing whether the client will tolerate that. The other two options may be beneficial, but they are not the best choices. If the client is comfortable, his or her agitation will decrease; this will improve respiratory status.
A nurse teaches a client with hepatitis C who is prescribed ribavirin (Copegus). Which statement should the nurse include in this client's discharge education? a. "Use a pill organizer to ensure you take this medication as prescribed." b. "Transient muscle aching is a common side effect of this medication." c. "Follow up with your provider in 1 week to test your blood for toxicity." d. "Take your radial pulse for 1 minute prior to taking this medication."
ANS: A Treatment of hepatitis C with ribavirin takes up to 48 weeks, making compliance a serious issue. The nurse should work with the client on a strategy to remain compliant for this length of time. Muscle aching is not a common side effect. The client will be on this medication for many weeks and does not need a blood toxicity examination. There is no need for the client to assess his or her radial pulse prior to taking the medication.
A client with a new pulmonary embolism (PE) is anxious. What nursing actions are most appropriate? (Select all that apply.) a. Acknowledge the frightening nature of the illness. b. Give a back rub.. c. Give simple explanations of what is happening. d. Request a prescription for antianxiety medication. e. Stay with the client and speak in a quiet, calm voice.
ANS: A, B, C, E Clients with PEs are often anxious. The nurse can acknowledge the client's fears, provide comfort measures, give simple explanations the client will understand, and stay with the client. Using a calm, quiet voice is also reassuring. Sedatives and antianxiety medications are not used routinely because they can contribute to hypoxia. If the client's anxiety is interfering with diagnostic testing or treatment, they can be used, but there is no evidence that this is the case.
A nurse is caring for a client who is on mechanical ventilation. What actions will promote comfort in this client? (Select all that apply.) a. Allow visitors at the client's bedside. b. Ensure the client can communicate if awake. c. Keep the television tuned to a favorite channel. d. Provide back and hand massages when turning. e. Turn the client every 2 hours or more.
ANS: A, B, D, E There are many basic care measures that can be employed for the client who is on a ventilator. Allowing visitation, providing a means of communication, massaging the client's skin, and routinely turning and repositioning the client are some of them. Keeping the TV on will interfere with sleep and rest.
A nurse assesses a client who is experiencing diabetic ketoacidosis (DKA). For which manifestations should the nurse monitor the client? (Select all that apply.) a. Deep and fast respirations b. Decreased urine output c. Tachycardia d. Dependent pulmonary crackles e. Orthostatic hypotension
ANS: A, C, E DKA leads to dehydration, which is manifested by tachycardia and orthostatic hypotension. Usually clients have Kussmaul respirations, which are fast and deep. Increased urinary output (polyuria) is severe. Because of diuresis and dehydration, peripheral edema and crackles do not occur.
A nurse cares for a client with congestive heart failure who has a regular cardiac rhythm of 128 beats/min. For which physiologic alterations should the nurse assess? (Select all that apply.) a. Decrease in cardiac output b. Increase in cardiac output c. Decrease in blood pressure d. Increase in blood pressure e. Decrease in urine output f. Increase in urine output
ANS: A, D, E Elevated heart rates in a healthy client initially cause blood pressure and cardiac output to increase. However, in a client who has congestive heart failure or a client with long-term tachycardia, ventricular filling time, cardiac output, and blood pressure eventually decrease. As cardiac output and blood pressure decrease, urine output will fall.
A nurse cares for a client with hepatic portal-systemic encephalopathy (PSE). The client is thin and cachectic in appearance, and the family expresses distress that the client is receiving little dietary protein. How should the nurse respond? a. "A low-protein diet will help the liver rest and will restore liver function." b. "Less protein in the diet will help prevent confusion associated with liver failure." c. "Increasing dietary protein will help the client gain weight and muscle mass." d. "Low dietary protein is needed to prevent fluid from leaking into the abdomen."
ANS: B A low-protein diet is ordered when serum ammonia levels increase and/or the client shows signs of PSE. A low-protein diet helps reduce excessive breakdown of protein into ammonia by intestinal bacteria. Encephalopathy is caused by excess ammonia. A low-protein diet has no impact on restoring liver function. Increasing the client's dietary protein will cause complications of liver failure and should not be suggested. Increased intravascular protein will help prevent ascites, but clients with liver failure are not able to effectively synthesize dietary protein.
A nurse is caring for a client after surgery. The client's respiratory rate has increased from 12 to 18 breaths/min and the pulse rate increased from 86 to 98 beats/min since they were last assessed 4 hours ago. What action by the nurse is best? a. Ask if the client needs pain medication. b. Assess the client's tissue perfusion further. c. Document the findings in the client's chart. d. Increase the rate of the client's IV infusion.
ANS: B Signs of the earliest stage of shock are subtle and may manifest in slight increases in heart rate, respiratory rate, or blood pressure. Even though these readings are not out of the normal range, the nurse should conduct a thorough assessment of the client, focusing on indicators of perfusion. The client may need pain medication, but this is not the priority at this time. Documentation should be done thoroughly but is not the priority either. The nurse should not increase the rate of the IV infusion without an order.
After teaching a client who has been diagnosed with hepatitis A, the nurse assesses the client's understanding. Which statement by the client indicates a correct understanding of the teaching? a. "Some medications have been known to cause hepatitis A." b. "I may have been exposed when we ate shrimp last weekend." c. "I was infected with hepatitis A through a recent blood transfusion." d. "My infection with Epstein-Barr virus can co-infect me with hepatitis A."
ANS: B The route of acquisition of hepatitis A infection is through close personal contact or ingestion of contaminated water or shellfish. Hepatitis A is not transmitted through medications, blood transfusions, or Epstein-Barr virus. Toxic and drug-induced hepatitis is caused from exposure to hepatotoxins, but this is not a form of hepatitis A. Hepatitis B can be spread through blood transfusions. Epstein-Barr virus causes a secondary infection that is not associated with hepatitis A.
A nurse assesses a client who has diabetes mellitus. Which arterial blood gas values should the nurse identify as potential ketoacidosis in this client? a. pH 7.38, HCO3- 22 mEq/L, PCO2 38 mm Hg, PO2 98 mm Hg b. pH 7.28, HCO3- 18 mEq/L, PCO2 28 mm Hg, PO2 98 mm Hg c. pH 7.48, HCO3- 28 mEq/L, PCO2 38 mm Hg, PO2 98 mm Hg d. pH 7.32, HCO3- 22 mEq/L, PCO2 58 mm Hg, PO2 88 mm Hg
ANS: B When the lungs can no longer offset acidosis, the pH decreases to below normal. A client who has diabetic ketoacidosis would present with arterial blood gas values that show primary metabolic acidosis with decreased bicarbonate levels and a compensatory respiratory alkalosis with decreased carbon dioxide levels.
A nurse is planning care for a client who is anxious and irritable. The client's arterial blood gas values are pH 7.30, PaO2 96 mm Hg, PaCO2 43 mm Hg, and HCO3- 19 mEq/L. Which questions should the nurse ask the client and spouse when developing the plan of care? (Select all that apply.) a. "Are you taking any antacid medications?" b. "Is your spouse's current behavior typical?" c. "Do you drink any alcoholic beverages?" d. "Have you been experiencing any vomiting?" e. "Are you experiencing any shortness of breath?"
ANS: B C This client's symptoms of anxiety and irritability are related to a state of metabolic acidosis. The nurse should ask the client's spouse or family members if the client's behavior is typical for him or her, and establish a baseline for comparison with later assessment findings. The nurse should also assess for alcohol intake because alcohol can change a client's personality and cause metabolic acidosis. The other options are not causes of metabolic acidosis
A nurse is assessing clients who are at risk for acid-base imbalance. Which clients are correctly paired with the acid-base imbalance? (Select all that apply.) a. Metabolic alkalosis - Young adult who is prescribed intravenous morphine sulfate for pain b. Metabolic acidosis - Older adult who is following a carbohydrate-free diet c. Respiratory alkalosis - Client on mechanical ventilation at a rate of 28 breaths/min d. Respiratory acidosis - Postoperative client who received 6 units of packed red blood cells e. Metabolic alkalosis - Older client prescribed antacids for gastroesophageal reflux disease
ANS: B C E Respiratory acidosis often occurs as the result of underventilation. The client who is taking opioids, especially IV opioids, is at risk for respiratory depression and respiratory acidosis. One cause of metabolic acidosis is a strict low-calorie diet or one that is low in carbohydrate content. Such a diet increases the rate of fat catabolism and results in the formation of excessive ketoacids. A ventilator set at a high respiratory rate or tidal volume will cause the client to lose too much carbon dioxide, leading to an acid deficit and respiratory alkalosis. Citrate is a substance used as a preservative in blood products. It is not only a base, it is also a precursor for bicarbonate. Multiple units of packed red blood cells could cause metabolic alkalosis. Sodium bicarbonate antacids may increase the risk of metabolic alkalosis.
An emergency room nurse assesses a female client. Which assessment findings should alert the nurse to request a prescription for an electrocardiogram? (Select all that apply.) a. Hypertension b. Fatigue despite adequate rest c. Indigestion d. Abdominal pain e. Shortness of breath
ANS: B, C, E Women may not have chest pain with myocardial infarction, but may feel discomfort or indigestion. They often present with a triad of symptoms—indigestion or feeling of abdominal fullness, feeling of chronic fatigue despite adequate rest, and feeling unable to catch their breath. Frequently, women are not diagnosed and therefore are not treated adequately. Hypertension and abdominal pain are not associated with acute coronary syndrome.
A nurse is caring for five clients. For which clients would the nurse assess a high risk for developing a pulmonary embolism (PE)? (Select all that apply.) a. Client who had a reaction to contrast dye yesterday b. Client with a new spinal cord injury on a rotating bed c. Middle-aged man with an exacerbation of asthma d. Older client who is 1-day post hip replacement surgery e. Young obese client with a fractured femur
ANS: B, D, E Conditions that place clients at higher risk of developing PE include prolonged immobility, central venous catheters, surgery, obesity, advancing age, conditions that increase blood clotting, history of thromboembolism, smoking, pregnancy, estrogen therapy, heart failure, stroke, cancer (particularly lung or prostate), and trauma. A contrast dye reaction and asthma pose no risk for PE.
A client is on a ventilator and is sedated. What care may the nurse delegate to the unlicensed assistive personnel (UAP)? a. Assess the client for sedation needs. b. Get family permission for restraints. c. Provide frequent oral care per protocol. d. Use nonverbal pain assessment tools.
ANS: C The client on mechanical ventilation needs frequent oral care, which can be delegated to the UAP. The other actions fall within the scope of practice of the nurse.
The nurse caring for the client with heart failure is concerned that digoxin toxicity has developed. For which signs and symptoms of digoxin toxicity does the nurse notify the provider? Select all that apply. a. Hypokalemia b. Sinus bradycardia c. Fatigue d. Serum digoxin level of 1.5 e. Anorexia
B, C, E: Digoxin toxicity may be manifested by bradycardia, fatigue, and/or anorexia. A - Incorrect: Hypokalemia causes increased sensitivity to the drug and toxicity, but it is not a symptom of toxicity. D - Incorrect: This represents a therapeutic value that is between 0.8 and 2.0.
The nurse is teaching the main principles of hemodialysis to a client with chronic kidney disease. Which statement by the client indicates a need for further teaching by the nurse? a. "My sodium level changes by movement from the blood into the dialysate." b. "Dialysis works by movement of wastes from lower to higher concentration." c. "Extra fluid can be pulled from the blood by osmosis." d. "The dialysate is similar to blood but without any toxins."
b. "Dialysis works by movement of wastes from lower to higher concentration."
A nurse assesses a client who potentially has hyperaldosteronism. Which serum laboratory values should the nurse associate with this disorder? (Select all that apply.) a. Sodium: 150 mEq/L b. Sodium: 130 mEq/L c. Potassium: 2.5 mEq/L d. Potassium: 5.0 mEq/L e. pH: 7.28 f. pH: 7.50
a. Sodium: 150 mEq/L c. Potassium: 2.5 mEq/L f. pH: 7.50 (Aldosterone increases reabsorption of sodium and excretion of potassium. Hyperaldosteronism causes hypernatremia, hypokalemia, and metabolic alkalosis. Hyponatremia, hyperkalemia, and acidosis are manifestations of adrenal insufficiency.)
After teaching a client who has alcohol-induced cirrhosis, a nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching? a. "I cannot drink any alcohol at all anymore." b. "I need to avoid protein in my diet." c. "I should not take over-the-counter medications." d. "I should eat small, frequent, balanced meals."
b. "I need to avoid protein in my diet." Based on the degree of liver involvement and decreased function, protein intake may have to be decreased. However, some protein is necessary for the synthesis of albumin and normal healing. The other statements indicate accurate understanding of self-care measures for this client
A nurse cares for a client who possibly has syndrome of inappropriate antidiuretic hormone (SIADH). The clients serum sodium level is 114 mEq/L. Which action should the nurse take first? a. Consult with the dietitian about increased dietary sodium. b. Restrict the clients fluid intake to 600 mL/day. c. Handle the client gently by using turn sheets for re-positioning. d. Instruct unlicensed assistive personnel to measure intake and output.
b. Restrict the clients fluid intake to 600 mL/day. (With SIADH, clients often have dilutional hyponatremia. The client needs a fluid restriction, sometimes to as little as 500 to 600 mL/24 hr. Adding sodium to the clients diet will not help if he or she is retaining fluid and diluting the sodium. The client is not at increased risk for fracture, so gentle handling is not an issue. The client should be on intake and output; however, this will monitor only the clients intake, so it is not the best answer. Reducing intake will help increase the clients sodium.)
The charge nurse is orienting a float nurse to an assigned client with an arteriovenous (AV) fistula for hemodialysis in her left arm. Which action by the float nurse would be considered unsafe? a. Palpating the access site for a bruit or thrill b. Using the right arm for a blood pressure reading c. Administering intravenous fluids through the AV fistula d. Checking distal pulses in the left arm
c. Administering intravenous fluids through the AV fistula
The nurse is taking the vital signs of a client after hemodialysis. Blood pressure is 110/58 mm Hg, pulse 66 beats/min, and temperature is 99.8° F (37.6° C). What is the most appropriate action by the nurse? a. Administer fluid to increase blood pressure. b. Check the white blood cell count. c. Monitor the client's temperature. d. Connect the client to an electrocardiographic (ECG) monitor.
c. Monitor the client's temperature.
The nurse is educating a group of women about the differences in symptoms of myocardial infarction (MI) in men versus those in women. Which information should be included? a. Men do not tend to report chest pain. b. Men are more likely than women to die after MI. c. Men more than women tend to deny the importance of symptoms. d. Women may experience extreme fatigue and dizziness as sole symptoms.
d. Women may experience extreme fatigue and dizziness as sole symptoms. Women may have atypical symptoms, including absence of chest pain. Women often present with a "triad" of symptoms. In addition to indigestion or a feeling of abdominal fullness, chronic fatigue despite adequate rest and feeling an inability to "catch the breath" (dyspnea) are also common in heart disease. The client may also describe the sensation as aching, choking, strangling, tingling, squeezing, constricting, or vise-like. Men do report chest pain. Women have higher mortality from MI than men. Because of differences in symptoms, denial may occur more often in women.
A client is hospitalized in the oliguric phase of acute kidney injury (AKI) and is receiving tube feedings. The nurse is teaching the client's spouse about the kidney-specific formulation for the enteral solution compared to standard formulas. What components should be discussed in the teaching plan? (Select all that apply.) a. Lower sodium b. Higher calcium c. Lower potassium d. Higher phosphorus e. Higher calories
ANS: A, C, E Many clients with AKI are too ill to meet caloric goals and require tube feedings with kidney-specific formulas that are lower in sodium, potassium, and phosphorus, and higher in calories than are standard formulas.
A nurse assesses a client who is receiving total parenteral nutrition. For which adverse effects related to an acid-base imbalance should the nurse assess? (Select all that apply.) a. Positive Chvostek's sign b. Elevated blood pressure c. Bradycardia d. Increased muscle strength e. Anxiety and irritability
ANS: A E A client receiving total parenteral nutrition is at risk for metabolic alkalosis. Manifestations of metabolic alkalosis include positive Chvostek's sign, normal or low blood pressure, increased heart rate, skeletal muscle weakness, and anxiety and irritability.
The nurse caring for mechanically ventilated clients uses best practices to prevent ventilator-associated pneumonia. What actions are included in this practice? (Select all that apply.) a. Adherence to proper hand hygiene b. Administering anti-ulcer medication c. Elevating the head of the bed d. Providing oral care per protocol e. Suctioning the client on a regular schedule
ANS: A, B, C, D The "ventilator bundle" is a group of care measures to prevent ventilator-associated pneumonia. Actions in the bundle include using proper hand hygiene, giving anti-ulcer medications, elevating the head of the bed, providing frequent oral care per policy, preventing aspiration, and providing pulmonary hygiene measures. Suctioning is done as needed.
A nurse teaches a client with a new permanent pacemaker. Which instructions should the nurse include in this client's teaching? (Select all that apply.) a. "Until your incision is healed, do not submerge your pacemaker. Only take showers." b. "Report any pulse rates lower than your pacemaker settings." c. "If you feel weak, apply pressure over your generator." d. "Have your pacemaker turned off before having magnetic resonance imaging (MRI)." e. "Do not lift your left arm above the level of your shoulder for 8 weeks."
ANS: A, B, E The client should not submerge in water until the site has healed; after the incision is healed, the client may take showers or baths without concern for the pacemaker. The client should be instructed to report changes in heart rate or rhythm, such as rates lower than the pacemaker setting or greater than 100 beats/min. The client should be advised of restrictions on physical activity for 8 weeks to allow the pacemaker to settle in place. The client should never apply pressure over the generator and should avoid tight clothing. The client should never have MRI because, whether turned on or off, the pacemaker contains metal. The client should be advised to inform all health care providers that he or she has a pacemaker.
A client has intra-arterial blood pressure monitoring after a myocardial infarction. The nurse notes the client's heart rate has increased from 88 to 110 beats/min, and the blood pressure dropped from 120/82 to 100/60 mm Hg. What action by the nurse is most appropriate? a. Allow the client to rest quietly. b. Assess the client for bleeding. c. Document the findings in the chart. d. Medicate the client for pain.
ANS: B A major complication related to intra-arterial blood pressure monitoring is hemorrhage from the insertion site. Since these vital signs are out of the normal range, are a change, and are consistent with blood loss, the nurse should assess the client for any bleeding associated with the arterial line. The nurse should document the findings after a full assessment. The client may or may not need pain medication and rest; the nurse first needs to rule out any emergent bleeding.
A nurse cares for a client with hepatitis C. The client's brother states, "I do not want to contract this infection, so I will not go into his hospital room." How should the nurse respond? a. "If you wear a gown and gloves, you will not get this virus." b. "Viral hepatitis is not spread through casual contact." c. "This virus is only transmitted through a fecal specimen." d. "I can give you an update on your brother's status from here."
ANS: B Although family members may be afraid that they will contract hepatitis C, the nurse should educate the client's family about how the virus is spread. Viral hepatitis, or hepatitis C, is spread via blood-to-blood transmission and is associated with illicit IV drug needle sharing, blood and organ transplantation, accidental needle sticks, unsanitary tattoo equipment, and sharing of intranasal cocaine paraphernalia. Wearing a gown and gloves will not decrease the transmission of this virus. Hepatitis C is not spread through casual contact or a fecal specimen. The nurse would be violating privacy laws by sharing the client's status with the brother.
A client is having a peritoneal dialysis treatment. The nurse notes an opaque color to the effluent. What is the priority action by the nurse? a. Warm the dialysate solution in a microwave before instillation. b. Take a sample of the effluent and send to the laboratory. c. Flush the tubing with normal saline to maintain patency of the catheter. d. Check the peritoneal catheter for kinking and curling.
ANS: B An opaque or cloudy effluent is the first sign of peritonitis. A sample of the effluent would need to be sent to the laboratory for culture and sensitivity in order to administer the correct antibiotic. Warming the dialysate in a microwave and flushing the tubing are not safe actions by the nurse. Checking the catheter for obstruction is a viable option but will not treat the peritonitis.
A client is recovering from a kidney transplant. The client's urine output was 1500 mL over the last 12-hour period since transplantation. What is the priority assessment by the nurse? a. Checking skin turgor b. Taking blood pressure c. Assessing lung sounds d. Weighing the client
ANS: B By taking blood pressure, the nurse is assessing for hypotension that could compromise perfusion to the new kidney. The nurse then should notify the provider immediately. Skin turgor, lung sounds, and weight could give information about the fluid status of the client, but they are not the priority assessment.
After teaching a client who was malnourished and is being discharged, a nurse assesses the client's understanding. Which statement indicates the client correctly understood teaching to decrease risk for the development of metabolic acidosis? a. "I will drink at least three glasses of milk each day." b. "I will eat three well-balanced meals and a snack daily." c. "I will not take pain medication and antihistamines together." d. "I will avoid salting my food when cooking or during meals."
ANS: B Starvation or a diet with too few carbohydrates can lead to metabolic acidosis by forcing cells to switch to using fats for fuel and by creating ketoacids as a by-product of excessive fat metabolism. Eating sufficient calories from all food groups helps reduce this risk.
An emergency room nurse assesses a client with potential liver trauma. Which clinical manifestations should alert the nurse to internal bleeding and hypovolemic shock? (Select all that apply.) a. Hypertension b. Tachycardia c. Pallor d. Confusion e. Shallow respirations
ANS: B, C, D Symptoms of hemorrhage and hypovolemic shock include hypotension, tachycardia, tachypnea, pallor, diaphoresis, cool and clammy skin, and confusion
A client is receiving an infusion of tissue plasminogen activator (t-PA). The nurse assesses the client to be disoriented to person, place, and time. What action by the nurse is best? a. Assess the client's pupillary responses. b. Request a neurologic consultation. c. Stop the infusion and call the provider. d. Take and document a full set of vital signs.
ANS: C A change in neurologic status in a client receiving t-PA could indicate intracranial hemorrhage. The nurse should stop the infusion and notify the provider immediately. A full assessment, including pupillary responses and vital signs, occurs next. The nurse may or may not need to call a neurologist.
A nurse assesses a client who is being treated for hyperglycemic-hyperosmolar state (HHS). Which clinical manifestation indicates to the nurse that the therapy needs to be adjusted? a. Serum potassium level has increased. b. Blood osmolarity has decreased. c. Glasgow Coma Scale score is unchanged. d. Urine remains negative for ketone bodies.
ANS: C A slow but steady improvement in central nervous system functioning is the best indicator of therapy effectiveness for HHS. Lack of improvement in the level of consciousness may indicate inadequate rates of fluid replacement. The Glasgow Coma Scale assesses the client's state of consciousness against criteria of a scale including best eye, verbal, and motor responses. An increase in serum potassium, decreased blood osmolality, and urine negative for ketone bodies do not indicate adequacy of treatment.
The nurse is teaching a client how to increase the flow of dialysate into the peritoneal cavity during dialysis. Which statement by the client demonstrates a correct understanding of the teaching? a. "I should leave the drainage bag above the level of my abdomen." b. "I could flush the tubing with normal saline if the flow stops." c. "I should take a stool softener every morning to avoid constipation." d. "My diet should have low fiber in it to prevent any irritation."
ANS: C Inflow and outflow problems of the dialysate are best controlled by preventing constipation. A daily stool softener is the best option for the client. The drainage bag should be below the level of the abdomen. Flushing the tubing will not help with the flow. A diet high in fiber will also help with a constipation problem.
A nurse assesses a client with diabetes mellitus 3 hours after a surgical procedure and notes the client's breath has a "fruity" odor. Which action should the nurse take? a. Encourage the client to use an incentive spirometer. b. Increase the client's intravenous fluid flow rate. c. Consult the provider to test for ketoacidosis. d. Perform meticulous pulmonary hygiene care.
ANS: C The stress of surgery increases the action of counterregulatory hormones and suppresses the action of insulin, predisposing the client to ketoacidosis and metabolic acidosis. One manifestation of ketoacidosis is a "fruity" odor to the breath. Documentation should occur after all assessments have been completed. Using an incentive spirometer, increasing IV fluids, and performing pulmonary hygiene will not address this client's problem.
